COVID-19 Pandemic Responses among National Guard Service Members: Stressors, Coping Strategies, Sleep Difficultiesand Substance Use

The National Guard (NG) served as a critical component of the US COVID-19 response while concurrently managing personal COVID-19 responses. Understanding pandemic-related concerns, sleep difficulties, increased substance use, and stress management strategies can promote readiness for subsequent disasters. We surveyed 3221 NG service members (75% Army; 79% enlisted; 52% 30–49 years; 81% male) during COVID-19 (August-November 2020). Almost half were activated in response to COVID-19 (mean = 18.6 weeks) and completed the survey 2–3 months post-activation. Service members indicated great concern about family health (39%), the indefinite nature of the pandemic (35%), and their financial situation (23%). Over one-third reported changes in usual sleep amount, 33% described poor sleep quality, and 21% had trouble falling/staying asleep. Increased substance use was reported by 30%, including increased alcohol (13.5%), tobacco (9%), and caffeine/energy drinks (20.1%) consumption. Chi-square analyses and analyses of variance found those who activated reported more increased tobacco and caffeine/energy drink use versus non-activated, with no sleep difficulties nor alcohol use differences. Helpful stress management strategies included spending time outdoors (53%), exercising (48%), talking to family/friends (38%), and having a daily routine (38%). Specific health-, financial-, and job-related stressors were associated with COVID-19. Incorporating stress management in planning/preventive efforts promotes resilience during disasters.


Introduction
Since the beginning of 2020, the focus of the world has been on the extensive impact of the COVID-19 pandemic. This prolonged crisis has had a substantial adverse effect on the mental and behavioral health of individuals, and in particular, those who are responsible for responding to disasters. In the United States, National Guard (NG) service members are often deployed as first responders during national emergencies. The COVID-19 pandemic was no exception, and the NG has served as a critical component of the United States' response. As with the rest of the Nation, NG service members have also been managing personal pandemic-related adversities and concerns. NG service members have experienced a unique combination of pandemic-related challenges, putting them at risk for adverse psychological and behavioral responses, such as sleep difficulties and increased substance use. To promote military readiness and provide support to NG service members, it is important to better understand their specific pandemic-related concerns, as well as strategies that they found helpful in managing disaster-related stress. In addition, identifying risk and protective factors associated with COVID-19 mental and behavioral health outcomes for both NG service members who were and were not activated in response to COVID-19 provides opportunities to identify targets for preventive interventions and may foster resilience.
Sleep difficulties are prevalent among some service members [1][2][3][4], with 16.4% of Army NG soldiers reporting moderate or severe levels of clinical insomnia [3]. Conditions specifically associated with deployment, including poor sleep environments and high operations tempo, may exacerbate sleep difficulties [2,5]. Sleep difficulties are also associated with psychological problems, impaired functioning and readiness, and mission-related errors [3,6,7]. Efforts to mitigate sleep difficulties and address high operational demands among military populations often result in increased caffeine/energy drink consumption [8], reported by one in six soldiers [9]. Similarly, problematic alcohol use has been identified in 16.5% of state NG soldiers [10], with a higher likelihood of alcohol problems identified among Army Reserve and National Guard (R/NG) soldiers as compared with those who are on active duty [11,12].
In the case of the COVID-19 pandemic, psychological and behavioral consequences have been substantial. Rates of US adults reporting increased mental health problems ranged from 40-56%, with 13% indicating that the pandemic was associated with initiating or increasing alcohol or substance use [13][14][15]. Further, several studies found increased sleep difficulties due to COVID-19 [16][17][18]. In a nationally representative US sample, 25% of individuals reported moderate to severe levels of insomnia during the pandemic [19]. First responders supporting COVID-19 efforts have been particularly vulnerable, with 7% of ICU staff working in nine hospitals in the United Kingdom reporting problem drinking during the summer of 2020 [20] and sleep problems identified among 31% of healthcare professionals [21]. Research has begun to examine responses to the COVID-19 pandemic among Veterans and military families. However, to our knowledge, studies have not yet been published that focus on military service members, and in particular the NG, the Armed Services component that provided the vast majority of military pandemic assistance. This underscores the importance of further assessment among NG service members who have and have not activated in response to COVID-19.
The current study examines the experiences of NG Unit (NGU) service members who provided support to a highly affected state, identified by the Centers for Disease Control and Prevention [22] as an early epicenter of the COVID-19 pandemic. We examined rates of sleep difficulties in the past month and increased substance consumption, specifically alcohol, tobacco, and caffeine/energy drink use. In addition, we report pandemic-related stressors that are unique to NGU service members and strategies that NG service members use to help manage pandemic-related stress. Understanding these outcomes may inform strategies to mitigate adverse psychological and behavioral responses, protect and prepare the force, and optimize readiness for additional waves of COVID-19 and similar future threats.

Participants
A total of 3993 Army and Air Force state NGU service members participated in the study between August and December 2020, with the majority of survey participation (75%) completed by mid-October. Of these participants, 46% (n = 1363) activated prior to the data collection period (i.e., spring and summer 2020; mean activation length = 18.6 weeks). Activated NGU service members completed the survey approximately 2-3 months postactivation. Study respondents represented approximately 25% of the total NGU population (23% of the Army NG and 14% of the Air NG).

Procedures
Online survey invitations were distributed by email to all of the specific state NGU members. NGU service members were informed of the opportunity to participate in the study by their unit leaders via an email that provided a link to the survey. Survey instructions indicated that study participation was voluntary and anonymous. Service members completed the surveys on their personal computers or mobile phones and indicated agreement and consent to participate by completing the online survey. Participants were informed that the survey included items regarding their work and personal experiences during the COVID-19 pandemic. Personally identifiable information was not collected; all transmitted and stored data were non-identifiable. Survey completion took approximately 20 min. The study was conducted in accordance with the Declaration of Helsinki and approved on 26 June 2020 by the Institutional Review Board of the Uniformed Services University of the Health Sciences in Bethesda, Maryland (Protocol DBS.2020.125).

Health and Well-Being Concerns
Participants indicated the degree to which they experienced concern about 11 stressful experiences in the past four weeks, which included the following: (1) getting COVID-19; (2) spreading COVID-19 to others; (3) the indefinite nature of the pandemic; (4) being isolated from others; (5) your physical health; (6) your emotional health; (7) your spiritual health; (8) the health of your family; (9) your financial situation; (10) loss of your job; and (11) running out of food or supplies. These items were developed for the current study based on discussion with subject matter experts in disaster response and NG leadership. (4) Extreme. The degree to which participants found it difficult to balance their concerns for their family and their work/employment over the past four weeks was assessed, with response options ranging from (0) Not at all difficult to (4) Extremely difficult. We dichotomized scores for each concern item, using a cut-off of 3+ (Very or Extremely difficult) to indicate high levels of concern. A sum score of each of the dichotomized items was also created to identify the level of general concern for each NGU service member.

Strategies for Managing Stress
Participants identified how helpful the following eight strategies were during the pandemic for managing stress: (1) talking to family or friends; (2) talking to mental health counselor; (3) community resources; (4) keeping to a daily routine; (5) exercise; (6) spending time outdoors; (7) religious/spiritual activities; and (8) activities online/computer/video games. Response options ranged from (0) Not at all to (4) Extremely. We dichotomized scores for each strategy item, using a cut-off of 3+ (Quite a Bit or Extremely helpful) to indicate high levels of helpfulness.

Mental Health Outcomes
Sleep difficulties. Extent and quality of sleep difficulties over the past four weeks were assessed using three items. Change in sleep amount was assessed based on responses to the following item: "Compared to your usual amount of sleep, how much sleep have you had per night over the past four weeks?" Response options included: (1) Less than usual; (2) About the same; and (3) More than usual. Sleep quality was based on the item, "How would you rate your sleep quality overall in the past four weeks?" with response options ranging from (1) Very bad to (4) Very good. A third item measuring trouble falling asleep or staying asleep included response options ranging from (1) Much less trouble than usual to (5) Much more trouble than usual.

Increased Substance Use
Increased substance use, specifically alcohol, tobacco, and caffeine/energy drink use, for two weeks or more since the onset of the COVID-19 pandemic (approximately 8 months) was assessed using three separate items. Participants who responded that they either increased their use or had stopped but started using again were categorized with (1) increased use, and those who had decreased their use or use stayed the same were categorized with (0) no increased use.

Statistical Analysis
Socio-demographics (age, gender, race, and marital status) and service-related characteristics (rank and military affiliation (Army, Air Force)), and COVID-19 activation were examined using descriptive statistics. Descriptive statistics also were used to identify rates of pandemic-related health and well-being concerns, strategies for managing stress, sleep difficulties in the past month, and increased alcohol, tobacco, and caffeine/energy drink use since the onset of COVID-19. Chi-square analyses and analyses of variance were conducted to examine the differences in concerns, strategies for managing stress, sleep difficulties, and increased substance use based on whether NGU participants were activated in response to COVID-19. Statistical analyses were conducted using SPSS software Version 28 [23].

Health and Well-Being Concerns
Among all NGU service members in the past four weeks, they reported being most concerned about (1) the health of their family (with 39.2% reporting that they were quite a bit or extremely concerned); (2) the indefinite nature of the pandemic (35.0%); (3) their financial situation (23.2%); (4) their physical health (21.1%); and (5) spreading COVID-19 to others (20.2%) (See Table 1 for all categories).
There was not a significant difference in the number of items about which NGU service members were highly concerned based on whether they activated (M(SD) = 2.25(2.92)) or did not activate (M(SD) = 2.36(2.90)). However, there were differences in rates of specific concerns based on activation status (Table 2). Chi-square analyses indicated that, as compared to NGU service members who activated, those who did not activate were more concerned about getting COVID-19 (19.0% of those who did not activate versus 15.5% of those who activated; χ 2 = 6.28, p ≤ 0.01); the indefinite nature of the pandemic (36.7% versus 32.9%; χ 2 = 4.60, p ≤ 0.05); being isolated from others (20.7% versus 15.0%, χ 2 = 16.31, p ≤ 0.001); and the health of their family (41.5% versus 36.2%; χ 2 = 8.61, p ≤ 0.01). Those who activated were more concerned about their financial situation than those who did not activate (25.5% of those who activated versus 21.3% of those who did not; χ 2 = 7.40, p ≤ 0.01); and the loss of their job (15.6% versus 13.3%, χ 2 = 2.98, p ≤ 0.05).
As a result of the pandemic, 5.5% (n = 175) of all NGU service members reported permanently losing their jobs, and 8.8% (n = 284) temporarily losing their jobs or being furloughed. Over 14% (n = 400) indicated that it was very or extremely difficult to balance their concerns for their families and their work, with this balance reported as more difficult among NGU members who did not activate (16.3%) versus those who did (11.6%; χ 2 = 12.61; p ≤ 0.001).

Sleep Difficulties
Approximately 35% of all NGU service members (35.%; n = 989) indicated that they experienced a change in their usual amount of sleep in the past four weeks, with 30.3% (n = 846) reporting that they slept less than usual and 5.1% (n = 143) sleeping more than usual (Table 3). One-third (n = 931) reported that their sleep quality was fairly bad or very bad, and 21.3% (n = 597) indicated that they had more trouble falling asleep or staying asleep during this period. There were no significant differences in any of the sleep difficulty characteristics based on whether participants activated in response to COVID-19.

Increased Substance Use
Among all participants, 30% (n = 839) reported an increase in at least one form of substance use for two weeks or more since the onset of the COVID-19 pandemic (Table 3). Specifically, 13.5% (n = 377) of all participants described an increase in alcohol use (and among those who reported drinking alcohol, 23.4% reported increased use), 9.0% (n = 251) described increased tobacco use (with 33.9% who smoke reporting increased use), and 20.1% (n = 562) reported increased caffeine/energy drink use (with 26.8% of those who use caffeine/energy drinks reporting increased use). Although there were no significant differences in increased alcohol use based on activation status, NGU service members who activated reported higher rates of increased tobacco use (10.9% of those who activated versus 7.4% who did not; χ 2 = 10.27, p ≤ 0.001) and increased caffeine/energy drink use (22.7% of those who activated versus 17.9% who did not; χ 2 = 9.72, p ≤ 0.001). When all substances were considered together, activated NGU service members reported a higher rate of increased use of any substance compared to those who had not activated (31.9% versus 28.4%, respectively; χ 2 = 3.84, p ≤ 0.05).

Discussion
In addition to their roles as first responders during the pandemic, NG service members are vulnerable to the same life disruptions related to COVID-19 as civilians. As a result, NG service members who are, and even those who are not, activated in response to COVID-19 face increased COVID-19 exposure and other health risks while they concurrently manage concerns related to civilian employment, personal finances, and family safety. These concerns may strain familial/interpersonal relationships, adversely affect psychological, behavioral, and physical health, and influence force readiness and functioning. In this study, NGU service members were most concerned about the health of their families, the indefinite nature of the pandemic, their physical health, and the spreading of COVID-19 to others. This study also identified strategies that service members identified as helpful in managing stress, including spending time outdoors, exercising, talking to family or friends, and keeping to a daily routine. Programs that promote these behaviors can help reduce stress and adverse psychological and behavioral outcomes.
The current study found that, in the past month, 30.3% of NGU service members reported sleeping less than usual, one-third reported poor sleep quality, and 21.3% indicated that they had more trouble falling or staying asleep. These rates were slightly elevated relative to those found in a nationally representative study of civilians during the pandemic [24], indicating that 19% of adults had trouble sleeping, with increased risk in females, consumption of high levels of alcohol use (i.e., >6 alcohol beverages per week), and reported stress [18,19,25,26]. The unique stressors of the NG population during the pandemic appear to have a particular impact on sleep for a notable proportion of service members. For NG and active duty Army soldiers, support resources such as leadership behaviors focused on promoting sleep (i.e., "sleep leadership" [7] can be effective management tools, increasing safety and reducing stress, mission-related errors, and burnout among unit members and other first responders [4,6].
In the current study, whether NGU service members activated in support of COVID-19 did not affect the likelihood of sleep difficulties. These findings correspond with previous research indicating that never-deployed US Army R/NG soldiers are at similar risk of negative mental health outcomes as those who had deployed [27,28]. However, those who have never deployed may face feelings of guilt and decreased connectedness, camaraderie, and value [29]. Crisis events, such as a pandemic or war, may also create a "stress on the force" that impacts all service members, regardless of their occupational responsibilities or exposures. Additional research that focuses on mental and behavioral health outcomes and specific types of sleep difficulties of NG service members during disasters, including those who are and are not activated, is warranted.
Almost one-third (30%) of NGU service members reported an increase in at least one form of substance use for two weeks or more since the onset of the pandemic. Specifically, in the total sample, 13.5% increased alcohol use, 9% increased tobacco use, and 20.1% increased caffeine/energy drink use). Increased use appeared to be a greater issue among NGU service members during the pandemic as compared with civilians, among whom 8% reported increased alcohol or substance use during this period [24]. Given the noteworthy rate of problematic alcohol use generally found in a previous systematic review of R/NG service members (14.5%) [11], the increase in alcohol consumption associated with the pandemic among this population suggests that focus on problematic alcohol use merits attention. As with sleep difficulties, the lack of difference in increased alcohol use between NGU service members who did and did not activate may reflect the extent to which the pandemic touched everyone, regardless of activation status. Interestingly, however, those who had activated in response to COVID-19 reported higher rates of tobacco and caffeine/energy drink use as compared with those who did not activate. Increased tobacco use in those who smoke (found among 33.9% of smokers) may reflect an effort to manage stressors associated with activation [30,31]. Further, increased consumption of caffeine/energy drinks in those who were activated may be used in an effort for NG service members to remain alert for extended working hours and under periods of high stress. It also may be associated with NG service members' attempts to contend with fatigue associated with disrupted sleep. However, substance use can exacerbate psychological and behavioral problems, including sleep difficulties [32][33][34]. These findings suggest that interventions that address substance use and encourage more adaptive health behaviors, such as sleep hygiene, among NG service members during the pandemic and other disasters may be important tools in maintaining behavioral and psychological health and promoting operational sustainment.
Several limitations should be considered in the interpretation of the study findings. This study focuses on an important population of NG service members and can directly inform research on the NG and other first responders. However, participants consisted of NGU members in one state, and the generalization of study findings to other military and civilian populations may be limited and requires further study. In addition, the higher proportion of males in the study sample may limit generalizability to wider populations. It is also important for future research to consider the type of work tasks in which activated service members are engaged, particularly those associated with high-stress work conditions, to help better understand their activation experience and how it may influence post-activation responses. Further, recognizing the influence of NGU service members' personal exposure to COVID-19, both their own and that of their families, provides additional insight into the impact of the activation experience on psychological and behavioral responses.

Conclusions
Screening for and being alert to service members who may be experiencing increased or problematic substance use and sleep difficulties can help identify those for whom to target preventive interventions. Additional research that focuses specifically on the influence of particular disaster-related concerns and strategies for managing stress in this population is important. The use of assessments and establishing training and interventions that directly address risk and protective factors may help prevent adverse psychological and behavioral responses, foster recovery, and promote force readiness.